Healthcare Provider Details

I. General information

NPI: 1699386789
Provider Name (Legal Business Name): ELITE MULTI SPECIALTY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 PROSPERITY DR STE 330
SILVER SPRING MD
20904-1655
US

IV. Provider business mailing address

12501 PROSPERITY DR STE 330
SILVER SPRING MD
20904-1655
US

V. Phone/Fax

Practice location:
  • Phone: 301-592-1780
  • Fax: 240-645-4013
Mailing address:
  • Phone: 301-592-1780
  • Fax: 240-645-4013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ADAORA PERPETUA NOUMMY
Title or Position: OFFICE ADMIN
Credential:
Phone: 301-592-1780